EMOTIONAL FREEDOM TECHNIQUE (EFT) CLIENT FORM

EFT Client Form
Part 1. Basic Info
Full Name *

First Name Last Name
Gender *

Male Female
Phone Number *

Area Code Phone Number
E-mail *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date of Birth *

Month Day Year
Part 2. Your Health
List any diagnosed health problems, physical or emotional. *
List your medications, if any. *
List any injuries you have, and your level of pain; mild, moderate or severe. *
Are you undergoing any type of therapy? *
Part 3. Your Issue
Why are you considering EFT? Please include physical, emotional, mental or spiritual issue. *
On a scale of one to 10 -- 1 being the least severe, and 10 being the most severe -- how severe is this issue in your life? *
When did this issue start, and what was happening in your life at the time? Was there emotional trauma? *
Have you sought treatment for this issue before? If so, what type? Did it help? *
TERMS AND CONDITIONS

By submitting this form, you understand and agree that Li Saul makes no claims to diagnose, treat, prevent, mitigate, or cure diseases. You agree to release Li Saul / INCENTRALISM from any claims as a result of any EFT session. She is not a licensed health care provider, and does not recommend that you stop using any prescribed medicine or therapy without consulting your health care provider. You understand that EFT is not meant to replace care from physicians, psychologists and other licensed healthcare providers.
By submitting this form, you agree to the Terms & Conditions. Click "Yes" to acknowledge. Then click SUBMIT. *

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EFT Client Form

Part 1. Basic Info

Part 2. Your Health

Part 3. Your Issue